The high-value care conversation

What do you do when a confused elderly patient's family asks for a head CT and you
think all that's needed is some fluids?

It may be tempting to run out of the room or order the test, but Emily Gottenborg,
MD, offered another option in her Hospital Medicine 2017 session on how to talk to
inpatients about high-value care.

With a few tips and tricks, “You can have these conversations about high-value
care with your patients effectively and feel better about it,” said Dr. Gottenborg,
an assistant professor of medicine at the University of Colorado in Denver.

The process starts with sitting down with the patient and family and accepting that
it will take some extra time to explain why you're not recommending a low-value test
or treatment, she explained.

On the bright side, the conversation might go more smoothly than you expect. “When
they ask us questions— ‘Why can't I have that CT?’ ‘When
can I get those antibiotics?’ —we make the assumption that they want
them and are demanding them from us. But actually they might not be,” said
Dr. Gottenborg. “We're not good at predicting this, so let's not make those
assumptions as we're sitting down to embark on these conversations.”

Here's another thing not to do: “Don't tell her that a head CT would be a waste
of money. She does not want to hear that,” Dr. Gottenborg said. Instead, explain
the potential harms to the patient from low-value care, whether it's radiation from
a CT scan or Clostridium difficile from antibiotics.

Patients and families may respond with more questions. “‘But, really,
doc, what is the downside of testing? Why can't I just get that CT? It would make
me feel so much better,’” said Dr. Gottenborg. “Here's where
you need to have your anecdotes ready. We've all had the CT or the head imaging that
shows the incidentaloma that leads us down a rabbit hole of unnecessary further testing,
anxiety, and stress for the patient.”

If you don't have your own anecdote appropriate to the situation, consider borrowing
someone else's. Dr. Gottenborg recommended the JAMA series “A Teachable Moment” as a source. “Trainees from the front
lines are writing these stories of harm that happens when you do low-value care,”
she said.

Some patients and family might persist, asking what will be done if your proposed
treatment plan doesn't work. “This is where I would encourage you to leave
the conversation open. Don't close the door with ‘You will never get that CT
this admission.’”

Instead, offer a time-bound contingency plan, suggesting that if the patient isn't
improving in 24 hours, the CT, or whatever intervention is requested, can be reconsidered.

Dr. Gottenborg also addressed a related question that hospitalists dread. “‘Can
I just stay in the hospital for another 24 hours?’ We hate this question. I
don't have any magical points for this, but I'm going to encourage you to think about
some of our ethical principles that guide all of our care,” she said.

Physicians are supposed to be providing benefit and doing no harm, both of which mean
that patients healthy enough to leave the hospital should not be kept in it. “We
know that harm happens in the hospital. Numbers to tuck away in case it's helpful
in your conversation: Four percent of patients in the hospital get a hospital-acquired
infection. … Almost 30% of patients can get delirious in the hospital.”

Another principle guiding health care is justice and fairness, which is a more delicate
concept to explain. “Patients sometimes respond poorly to this, so choose wisely
when you decide who you want to tell about the sicker patient in the ED, because that
can sometimes backfire,” said Dr. Gottenborg.

Another potentially tricky topic is requests for tests—for example, an echocardiogram—that
could be done after discharge. “‘Can you take care of that for me while
I'm here?’” said Dr. Gottenborg. “Historically, I think we've
all been taught as hospitalists, no, you should get that as an outpatient.”

She recommends handling this issue on a case-by-case basis. “If that echo tech
is ready to go … they can get it as the patient is walking out the door, then
maybe. Maybe that saves this particular patient a trip back to the clinic, working
out the transportation, ongoing confusion, delirium issues. However, if the echo tech
is backed up for the next three days, it's certainly not going to be worth the risk
of extra stay in the hospital,” she said. “I encourage you to take a
very patient-centered approach with this question.”

Some patient-centered written materials are also available to help with discussions
about high-value care. (ACP's resources are online.) Dr. Gottenborg recommended pamphlets developed by the Choosing Wisely campaign
and Consumer Reports that explain issues like overtreatment of urinary tract infections
in the elderly.

“It's clearly labeled ‘Consumer Reports' so patients know it's for them,
it's not coming from us as a way to change their behavior. It gives them quick tips
that they can tuck away,” she said.

The benefits of these pamphlets were proven in a study that distributed them to patients
filling benzodiazepine prescriptions, published in the June 2014 JAMA Internal Medicine. The pamphlet warned of the drugs' risks and offered advice on de-escalating. A third
of the patients discontinued or reduced their use of the drug.

Physicians can also provide resources to help patients deal with the cost of health
care. The solutions may be websites, such as Healthcare Blue Book and GoodRx, or hospital
staff. “Think about your social worker. They can provide other resources to
free up the budget—Meals on Wheels, transportation resources. The financial
counselor can often provide payment plans that the patients aren't aware of,”
said Dr. Gottenborg.

“If you can integrate this into your daily language of every patient encounter—’What's
it like paying for your health care? Have you had any trouble paying for those copays?
Are you worried about the cost of this hospitalization?’—you might get
some answers that you don't expect,” she said.

Of course, all of this conversation takes time, for which clinicians are currently
not paid, Dr. Gottenborg noted. “In the future, I do hope and expect that we
will have innovative reimbursement models that will help support value-based care
conversations and practicing high-value care,” she concluded.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.